BACKGROUND: Different reconstruction techniques after total mesorectal excision have been described, such as straight coloanal anastomosis, colonic J-pouch, side-to-end anastomosis and transverse coloplasty pouch. Establishing which technique is the best in functional terms is essential to improving a patient's quality of life. METHODS: We compared benefits and harms of different reconstructive techniques. The primary outcome was to compare functional results at 18 months after surgery (long-term). Secondary outcomes were the same as primary but at different time intervals (short-term and medium-term) and perioperative morbidity and mortality. RESULTS: Forty-one reports of 36 trials were included in the analysis. According to primary outcome, no significant difference was observed in terms of bowel frequency, while colonic J-pouch resulted in a lower incidence of faecal urgency only compared to side-to-end. Only up to 18 months after bowel restoration bowel frequency, fecal urgency and the number of individuals using anti-diarrheal medications were reduced in the colonic J-pouch group. No difference in mortality/morbidity could be assessed among the techniques, but a lower rate of anastomotic leak after side-to-end compared to straight coloanal anastomosis was observed. CONCLUSIONS: Evidence suggests that reconstruction with colonic J-pouch offers similar long-term benefits to straight coloanal anastomosis and Transverse coloplasty pouch, while superior to side-to-end.